Medical Equipment - Orthoses

Effective: May 15, 2018

By regulation, orthoses include only the following items:
 

• a custom-made foot orthotic
• an off-the-shelf foot orthotic
• custom-made footwear
• off-the-shelf orthopaedic footwear
• off-the-shelf footwear
• a permanent modification to footwear
• an ankle brace
• an ankle-foot orthosis
• a knee-ankle-foot orthosis
• a knee brace
• a hip brace
• an upper extremity brace
• a cranial helmet
• a torso or spine brace
• a foot abduction orthosis
• a toe orthosis
• orthosis accessories and supplies
• an Aircast/walking boot

[For information on eligibility for hearing aids and other medical equipment, see Related Links – Medical Equipment – Hearing Instruments and Medical Equipment and Devices.]

Effective: May 15, 2018

Orthoses are available to clients who are eligible for general health supplements. [For information on eligibility for general health supplements, see Related Links - Health Supplement Summary.] Clients living in Ministry of Health funded residential care facilities may also be considered. 

A requested item must meet the following:
 

• General Requirements for All Orthoses;

and

• Specific Requirements for each Individual Type of Orthosis.

General Requirements for All Orthoses 

A client requesting orthoses must meet the general requirements that apply to all orthoses:
 

• there are no resources available to the family unit to pay the cost of or obtain the item;
• the item is the least expensive, appropriate orthosis;
• only one orthosis per part of the body may be considered;

Note: one “resting” orthosis may also be considered for each part of the body.
 

• the item must be prescribed by a medical practitioner or nurse practitioner;
• the request must be pre-approved by the ministry prior to purchase;

Note: the ministry will not accept payment responsibility for orthoses purchased without prior approval, except in cases of a life-threatening emergency. For example, an injury related to a car accident, or a fracture.

 

• the ministry is satisfied that the item is medically essential to achieve or maintain basic functionality;
• the item is required for one or more of the following purposes:
  • to prevent surgery
  • for post-surgical care
  • to assist in physical healing from surgery, injury or disease
  • to improve physical functioning that has been impaired by a neuro-musculo-skeletal condition
• custom-made items will be considered when the following are met:
  • a medical practitioner or nurse practitioner confirms that a custom-made orthosis is medically required;
  • the custom-made orthosis is fitted by a certified orthotist, certified pedorthist, occupational therapist, physical therapist, or podiatrist.

Specific Requirements for each Individual Type of Orthosis

In addition to meeting the general requirements for all orthoses, a client must also meet the specific requirements for the requested type of item:

Note: not all orthoses have specific requirements

Type of Item	Specific Requirements
Custom-made Foot Orthotics	they must be made from a hand-cast mold the cost of one pair, including the assessment fee, must not exceed $450
Off-the-shelf Orthopaedic Footwear	the cost of one pair must not exceed $250 “off-the-shelf orthopaedic footwear” means footwear intentionally designed to accommodate a medical condition
Off-the-shelf Footwear	the cost of one pair must not exceed $125 must be required to accommodate a custom-made orthosis “off-the-shelf footwear” means conventional, non-orthopaedic footwear
Custom-made Footwear	the cost, including the assessment fee, must not exceed $1,650
Knee Brace	the medical practitioner or nurse practitioner who prescribed the knee brace must recommend that the knee brace must be worn at least 6 hours per day.
Upper Extremity Brace	the upper extremity brace must be intended to provide hand, finger, wrist, elbow or shoulder support
Cranial Helmet	must be a helmet prescribed by a medical practitioner or nurse practitioner and recommended for daily use in cases of self-abusive behaviour, seizure disorder, or to protect or facilitate healing of chronic wounds or cranial defects
Torso or Spine Brace	must be intended to provide pelvic, lumbar, lumbar-sacral, thoracic-lumbar-sacral, cervical-thoracic-lumbar-sacral, or cervical spine support
Orthosis Accessories and Supplies	only for orthoses that meet eligibility criteria must be medically essential for the use of the orthosis an example item is a brace under sleeve for skin protection up to 4 per orthosis may be provided each year

Effective: May 15, 2018

The ministry does not provide orthoses that do not meet the eligibility criteria above, including the following:
 

• a prosthetic and related supplies
• a plaster or fibreglass cast
• a hernia support
• an abdominal support

Effective: April 1, 2010

By regulation, the ministry requires that all other available resources must first be considered before requesting funding. For income assistance and disability assistance clients, other resources include (but are not limited to) accessing orthoses or funding through:
 

• other government programs (e.g., PharmaCare, Health Authorities, ICBC, WorkSafeBC, Veterans Affairs Canada)
• private insurance

If there are other resources available, the individual is not eligible for orthoses from the ministry. 

Co-funding may be considered when other resources cannot pay the entire cost. For example, if an insurance company will pay $500 for an item that costs $1,000, the ministry may consider funding the remaining $500 if all other eligibility criteria are met.

Note: When assessing orthoses eligibility for income or disability assistance clients, exempt assets are not considered. When assessing other resources for persons with a life-threatening health need or persons who are medical services only, see Related Links –Life-Threatening Health Needs and Medical Services Only.

Effective: April 1, 2010

The following guidelines outline factors considered by the ministry when determining if orthoses requests are medically essential to achieve or maintain basic functionality. 

These guidelines assist ministry staff when reviewing the information provided by the client’s medical practitioner or nurse practitioner and, when required, information from an orthotist, pedorthist, podiatrist, occupational therapist or physical therapist.

“Medically essential to achieve or maintain basic functionality” refers to a client’s need for orthoses due to an impairment which is necessary to perform their day-to-day activities in their home and/or community. 

Each orthosis request is reviewed on an individual basis and the client’s needs are taken into consideration. If the factors confirm that the item is medically essential to achieve or maintain basic functionality, and all other eligibility requirements have been met, the client is eligible for the requested item. 

Note: the information to be considered under each factor is not all-inclusive as it is important to preserve the discretion of the ministry decision maker and allow for flexibility to assess uncommon or unexpected circumstances.

When assessing the information provided to determine if the orthoses is medically essential to achieve or maintain basic functionality, the two factors to be considered are:

Factor 1: The client’s impairment

Information regarding the client’s impairment provides the medical basis for the item and the reason why it is being requested. The impairment may result from a number of different medical conditions that restrict the client’s functional ability.

When considering this factor, the following information is reviewed:
 

• The diagnosis provided by the medical practitioner or nurse practitioner to assist in determining if it is reasonable to expect that there are functional limitations and whether the medical condition presented is likely to need orthoses.
• The medical information provided to assist in determining the applicant’s level of functioning. This includes information regarding:
  • the reason for the orthosis request
  • how the client performs day-to-day activities in their home and/or community
  • whether the medical condition would deteriorate without the orthoses
  • physical skills or limitations (e.g., range of motion, ambulation, endurance, coordination and strength) in relation to the item requested 

Factor 2: The orthosis requested

The type of orthosis requested is reviewed to confirm that due to an impairment, the item is required for basic functionality. 

When considering this factor, the following information is reviewed:
 

• Description of the item that is being requested. 
• The type and condition of the client’s present orthosis (if applicable) to determine its appropriateness and why it is no longer meeting the needs of the client. This may indicate if repairs or modifications can be done to the existing item or if a replacement is needed.
• The adaptability of the orthosis if the client’s functional status is likely to change, to determine if the item is sustainable in meeting their anticipated medical needs. For example, is the requested knee-ankle-foot orthosis able to accommodate future modifications such as specialized knee hinges?

Examples where a request may be considered medically essential to achieve or maintain basic functionality:
 

• A client with a torn anterior cruciate ligament (ACL) is requesting a custom knee brace. The brace is prescribed by a medical practitioner and fitted by an orthotist. It is required to achieve walking ability to carry out basic activities such as grocery shopping, cooking and housekeeping.
• A client with severe osteoarthritis is requesting an off-the-shelf wrist brace. The brace is prescribed by a medical practitioner and required to maintain joint motion so the client can carry out personal care and housekeeping.

Examples where a request may not be considered medically essential to achieve or maintain basic functionality:
 

• A client with a torn anterior cruciate ligament (ACL) is requesting an off-the-shelf knee brace prescribed by a nurse practitioner. The brace is only for use in playing soccer. Sports are not considered “day-to-day activities.”

• The client does not have a medical condition or impairment requiring orthoses but wants custom-made shoes.

Effective: May 15, 2018

The ministry may consider repairing or replacing orthoses due to the item being damaged, worn out, or not functioning.

Repairs may be considered if all of the following are met:
 

• it is more economical to repair, rather than replace, the orthosis
• the orthosis has not been damaged by misuse
• if the orthosis was not previously provided by the ministry, all other eligibility requirements must be met (e.g., prescription)

Note: Repairs, including modifications, should be completed by an appropriate professional. For example, the professional who fitted the orthosis when it was first provided.

Replacement may be considered if all of the following are met:
 

• it is more economical to replace, rather than repair, the orthosis
• the orthosis has not been damaged by misuse
• the time period, if any, set out in the table below has passed

Note: The replacement time period does not apply when an item is required due to changes in a person’s medical condition or growth.

Orthosis	Replacement Time Period
Custom-made Foot Orthotics	3 years
Off-the-shelf Foot Orthotics	As needed
Custom-made Footwear	1 year
Modification to Footwear	1 year
Off-the-shelf Orthopaedic Footwear	1 year
Off-the-shelf Footwear	1 year
Ankle Brace	2 years
Ankle-Foot Orthosis	2 years
Knee-Ankle-Foot Orthosis	2 years
Knee Brace	4 years
Hip Brace	2 years
Upper Extremity Brace	2 years
Cranial Helmet	2 years
Torso or Spine Brace	2 years
Foot Abduction Orthosis	As needed
Toe Orthosis	1 year
Aircast/walking boot	As needed

Effective: April 1, 2010

Clients requesting medical equipment must first be determined to be eligible for general health supplements, including medical equipment. The following procedures must then be completed to assess eligibility for orthoses. [For procedures for other types of medical equipment, see Related Links – Medical Equipment – Hearing Instruments and Medical Equipment and Devices.]

Persons who are not income assistance or disability assistance recipients but require medical equipment for a direct and imminent life-threatening health need must meet the eligibility criteria for Life-Threatening Health Needs before being assessed for eligibility for medical equipment and devices [see Related Links – Life-Threatening Health Needs].

The ministry requires that all other available resources must first be considered before funding any requests. If there are other resources available, the individual is not eligible for medical equipment from the ministry. Co-funding may be considered when other resources cannot pay the entire cost [see Policy - No Other Resources].

Effective: May 15, 2018

The following procedures are to be used to determine eligibility for orthoses.

Requests for all orthoses
Point of Contact	1.	Confirm that the applicant is eligible for general health supplements or has been approved under life-threatening health needs [see Policy].
	2.	Provide the recipient with the Orthoses Request and Justification form (HR2894) and advise the recipient what information is required to complete the application. A quote for the requested item(s) is required for all orthotic requests. Note: for off the shelf items under $250, only sections 1 and 2 of the HR2894 are required to be completed or written prescription with diagnosis from medical practitioner or nurse practitioner.  For orthoses repairs, only a quote is required.
	3.	Forward the Service Request and all documentation to Health Assistance (HA) for adjudication. Ensure the service request has all required documentation and is ready for adjudication.
HA	1.	Assess application to ensure eligibility criteria are met and verify that there are no other resources available [see Policy].
	2.	If approved, a purchase authorization will be issued to the service provider and a copy sent to the client.  If denied, a letter including the reasons for the decision will be sent to the client.
	3.	Make a note of all details. Details include substantive reasons explaining what is requested and why the eligibility criteria are met (or not met). If the item is approved, include the cost of the item and the name of the service provider.